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How NT won the training campaign

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As TOFT draws to a close, Louise Tweddell examines its major achievements

When NT’s Time Out For Training (TOFT) campaign began in January this year, it stated one overarching aim – to ensure
that money and time were ringfenced for post-registration nurse training.

Six months later, nurses have good reason to celebrate. Following relentless pressure, and with much support, the campaign has made significant gains.

NT has secured a guarantee from seven of the 10 strategic health authorities that, for the current financial year, they will cease to divert education funding and will invest all of the relevant money in staff training. What’s more, five SHAs have pledged that the underspends on training for 2007–2008 will be reinvested in training activity for this financial year.

And further proof that the message was heard where it has the potential to be most effective came with the outcome of Lord Ara Darzi’s NHS Next Stage Review – which yielded two big moves on training.

In the first instance, changes are promised regarding the Multi-Professional Educational and Training (MPET) budget –the money SHAs receive from the government to pay for the education and training of all their healthcare employees. Under the reforms MPET funding arrangements look set to be replaced with a tariff-based system, which will allow training funds to follow individual students.

The review promises that detailed proposals around MPET will be developed over the coming months after key stakeholders have been consulted.

The review’s report, A High Quality Workforce, states: ‘We will improve transparency, promote fairness and reward quality in education funding.’

Second, the review reveals that from now on, the Healthcare Commission will include levels of staff satisfaction around training and education as an indicator in its Annual Health Check. This means that nurses and other healthcare staff will be able to avoid taking jobs at trusts that have a poor record of supporting post-registration training. In addition, they will be able to report their employer to the commission if they do not feel they are being given sufficient access to training.

The report says: ‘We will require every organisation that receives central funding for education and training to adopt
the Government Skills Pledge to publish its annual expenditure on CPD so that present and future employees can make choices that are informed.’

The results of NT’s campaign have been well received across the nursing profession and in parliament.

Liberal Democrat peer Baroness Tonge, who in May raised questions about inequities in nurse training in the House of Lords, says: ‘I think the campaign has been a brilliant effort. Here we have a government that has listened to the health service, has put a lot of money in and has realised that it is not enough on its own.

‘I am sure the campaign bore fruit in this area and I hope the government will stay in long enough to implement it all. It needs to put its money where its mouth is now.’

Meanwhile, Gail Adams, Unison’s head of nursing, says that the campaign ‘has helped to focus attention’.

But she remains cautious over some of the reforms. Referring to the move to enable nurses to hold their employer to account over post-registration training, she says: ‘It could place a lot of pressure on an individual – based on who they are and what their role is, they might not be able to do that – but it helps us. And it does give more teeth to the process.’

In terms of proposed changes to MPET funding, she warns that ‘the devil is always in the detail’, but adds that it ‘sounds like good news’.

Such optimism is a far cry from the way nurses were feeling in 2005, when they began to inform NT that their requests for training were being refused.

Training that the previous generation of nurses had taken for granted – from continuing professional development to mandatory training – began to grind to a halt in trusts across England.

By the summer of the following year, Council of Deans of Health research showed that during the 2005–2006
financial year, £135m had been top-sliced from the total MPET budget.

At the time, England’s SHA managers were knee-deep in financial crisis and were under pressure to balance their books. They saw their MPET budgets as a quick fix in helping to achieve this. But despite many using this money to paper financial cracks, the NHS still had a £530m deficit at the end of the year.

By now the evidence was not confined to anecdotal reports. The 2006 NHS Staff Survey, conducted by the Healthcare Commission, showed that in 2005, 79% of healthcare staff had experienced difficulty in accessing training. Shortly afterwards 60 universities axed post-registration courses.

The situation continued into 2006–2007, with nurses repeatedly reporting that they were being denied the vital training necessary to carry out their work.

In that year Unite/CPHVA found that there was a 40% cut to post-registration training places for health visitors and a report by the National Audit Committee found that 30% of permanent nurses and 70% of those on the bank were failing to receive mandatory training.

Around £350m was diverted from MPET in 2006–2007. The money had been used to help the NHS achieve financial balance. In the event, it actually helped produce a surplus of around £500m.

The government continued to refuse to ringfence MPET budgets but instead, in 2007, put in place a service level agreement around the funding. The spirit of this agreement was to encourage SHAs to spend training funds on local needs but in reality it lacked teeth and MPET allocations continued to be raided.

Against this backdrop, in January 2008 NT launched Time Out For Training to highlight the importance of post-registration training for nurses and patient safety, and to raise awareness among the wider profession, public and government about the difficulties nurses were facing in obtaining such training.

Its overarching aim was to persuade SHAs to guarantee that education funds would, in future, be spent solely on staff training.

As part of this goal, it also set out to persuade NHS trusts to guarantee sufficient training time would be set aside to ensure continuing professional development for nurses – and to provide adequate cover to allow that training to take place.

This year, a variety of reports, investigations and news stories have highlighted the lack of access for nurses to appropriate levels of post-registration training.

In January a report from the government’s Cancer Reform Strategy found that cancer teams were severely lacking clinically trained specialists.

Then, in February NHS workforce planners warned that cuts to nurse training would hamper the transition of care from the acute sector to the community. And in a separate move, the RCN called for nurses to be given more training in sexual health – in particular, training to fit a range of long-acting reversible contraception devices – to help reduce rates of teenage pregnancy.

In March trusts were criticised by the RCN for year-on-year planning based on financial concerns rather than future needs, and a survey from the University and College Union, the largest trade union and professional association for academics and lecturers, found that budget cuts were stretching nurse lecturers to the limit.

Meanwhile, Freedom of Information requests placed by NT revealed that as many as six SHAs were forecasting underspends of around £48m – just in nurse training alone – from their 2007–2008 budgets.

A glimmer of hope came at the end of March, as the government announced its MPET allocations for 2008–2009. The proportion of the budget used to fund nurses’ pre- and post-registration education increased by £210m.

In April education charity Education for Health was so concerned about the problems accessing post-registration nurse training, it launched a tool to help nurses build a business case supporting their training needs. It showed staff how to map national and local trends, Department of Health policy, clinical guidance and government targets against their chosen course, and therefore demonstrate how training would benefit both the practitioner and the wider NHS.

At the end of that month, it seemed like the TOFT message had hit the heart of government as health secretary Alan Johnson declared during a speech to RCN Congress in Birmingham that the lengths nurses were having to go to access training were unacceptable.

‘A key foundation for a strong and confident nursing profession is training and development. I often speak to nurses who invest in courses with their own time, utilising days off, paying their own fees,’ he said.

‘I am amazed at the sacrifices nurses make to acquire training that benefits the service. Nurses should not be expected to use their holiday time or contribute towards costs of training that help them meet the needs of their patients. High quality training and development is essential to supporting high quality care,’ he added.

Disappointingly, in May, in response to questions raised on behalf of NT by Baroness Tonge in the House of Lords, junior heath minister Lord Darzi said there was no plan for the DH to make SHAs carry over any underspends on education and training into the new financial year.

By June, NT discovered the actual final year-end spends for 2007–2008 on MPET from eight out of the 10 SHAs.

Four SHAs had topsliced £74m to help produce an overall surplus and six had underspent on their remaining budgets by nearly £30m. This meant that in total, more than £100m earmarked for education in 2007–2008 did not reach the frontline. At least a quarter of that money was from the part of the budget used for nurses’ training.

The end result is that since 2005, almost £600m has been taken away from NHS education and training – and that figure could increase when NHS London and NHS West Midlands confirm their final MPET spends for 2007–2008.

It had been widely believed that in 2006–2007 the reason why many nurses had not been able to access training was because SHAs had chosen to divert cash from their MPET budgets. But in June a report by the Commons public accounts committee revealed this was not necessarily the case.

David Nicholson, NHS chief executive, told the committee that the government itself imposed restrictions on SHA spending on healthcare training, in order for the health service to reach a surplus of £515m in 2006–2007.

Indeed, the cut in spending represented a ‘real reduction’ of 4% from the total MPET budget for that year, equating to £354m
in cash terms.

So, just how did NT’s TOFT campaign achieve its stated goals?

On the back of extensive editorial coverage in the magazine and online, nurses were encouraged to sign a Downing Street petition calling on the government to ringfence MPET funds and also to write to their MP to highlight problems with training.

In total, 1,146 nurses signed the petition, which was presented to government at the end of June by Howard Stoate MP, member of the Commons health select committee.

Dr Stoate said: ‘The fact that SHAs are still able to use training money for other purposes is not a position we should be in. I would have hoped the service level agreement would have helped with this.’

Nurses also wrote to their trusts to ask for better access to training, and support for the campaign came from far and wide, with a host of professional organisations, trade unions and patient groups pledging their support.

Peter Carter, RCN general secretary, said: ‘I’m delighted to give the Royal College of Nursing’s support to Nursing Times’ Time Out for Training Campaign.

‘Training should not be treated as a perk or an optional extra, and funds earmarked for staff training should not be used to cover shortfalls elsewhere.

‘It is vital that nurses continue to learn, develop and enhance their skills on the job if they are to provide patients with the very best quality care.

‘We know there is a strong link between core professional development and patient outcomes. Put simply, training can make the difference between life and death.’

Cheryll Adams, Unite/CPHVA lead professional officer, said: ‘Commissioners need to examine why successful companies consider staff training such a priority for investment before seeing it as a quick option for making savings in the NHS.

‘We fully support the call by Nursing Times for ringfenced training budgets in the NHS’.

Bev Hurst, founder of patient group and charity National Concern for Healthcare Infections, said: ‘Ringfencing funds is the only way to address the growing issues of patient care and safety.

‘Without ongoing, up-to-date training nurses cannot be expected to give safe care. Without our nurses there will be no NHS.

Without properly trained nurses there will be no patient safety within our NHS.

‘Without funds being ringfenced for their intended purpose, more and more patients will be put at risk.’

Support did not end there. Many NHS trusts wrote to NT to say they were behind the aims of TOFT and guaranteed not only commitment but also stated that their nurses would be given adequate levels of training and sufficient support in staff cover to carry this out.

And not only have seven SHAs promised to spend all of their training funds for 2008–2009 on training, one of them – East of England SHA – which diverted more than £30m of its MPET budget in 2007–2008, has made a three-year commitment to spend its entire MPET budget solely on education and training of all staff.

The campaign also received the backing of junior health minister Ann Keen. Speaking in June at a parliamentary briefing for MPs at the House of Commons, which was organised by NT, Ms Keen said: ‘It is unacceptable that nurses have to pay for their own training and have done it in their own time. While I am in this job I will do everything I can to make sure this stops. I give you my commitment.’

A lot has been achieved by the TOFT campaign in the last six months. The message that levels of access to post-registration training for nurses have, over the last three years, been diluted to unacceptable levels has been admitted by the government and progress should now be made as a result of Lord Darzi’s announcements.

TOFT has built a solid foundation from which nurses can continue to fight for the training they deserve to uphold the safety of patients and progress in their career.

However, there is no room for complacency and it is now up to nurses everywhere to take forward the TOFT message and ensure that post-registration training is never again sacrificed to balance the books.

The Impact of Time Out For Training

  • Funding arrangements for MPET will be replaced with a tariff-based system whereby training funds follow the student or trainee (NHS Next Stage Review)

  • The Healthcare Commission’s Annual Health Check will include an indicator on levels of staff satisfaction around training and education (NHS Next Stage Review)

  • Seven SHAs guarantee that education funds will be spent exclusively on training in 2008–2009, namely: North East; North West; Yorkshire and The Humber; East Midlands; West Midlands; East of England; and London

  • Five SHAs agree that money underspent on training in 2007–2008 will be reinvested in training activity this financial year, namely: NHS North West; NHS East of England; NHS Yorks and Humber; NHS East Midlands; and NHS London

  • An NT parliamentary briefing together with a petition of 1,146 signatures, ensured that the message was delivered to MPs

  • Awareness has been raised at all levels within the NHS and government of the importance of post-registration training

  • Nurses have been supported to lobby trusts and government over their training needs and requirements

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